General Dentists’ Perceptions of Educational

and Treatment Issues Affecting Access to Care

for Children with Special Health Care Needs
Paul S. Casamassimo, D.D.S., M.S.; N. Sue Seale, D.D.S., M.S.D.; Kelley Ruehs, D.D.S.
Abstract: This study analyzed a data subset of a national survey of general dentists conducted in 2001 to determine their overall
care of children with special health care needs (CSHCN). In the survey, dentists were asked to respond to questions in the
following areas: did they provide care for CSHCN (children with cerebral palsy, mental retardation, and those who are medically
compromised); what were their perceptions of the training they received in dental school related to CSHCN; what was their
interest in additional training for CSHCN; and what factors influenced their willingness to provide care for CSHCN? Only about
10 percent see CSHCN often or very often, and only one in four respondents had hands-on experience with these patients in
dental school. Postgraduate education in general practice or advanced general dentistry residency had no effect on willingness to
care for CSHCN. Older dentists, those accepting Medicaid for all children, and those practicing in small communities were more
likely to see CSHCN. Dentists willing to see CSHCN also were more likely to perform procedures associated with special needs
and underserved child populations including pharmacologic management and stainless steel crowns. Dentists with hands-on
educational experiences in dental schools with CSHCN were less likely to consider such factors as level of disability and patient
behavior as obstacles to care and were more likely to desire additional education in care of CSHCN.
Dr. Casamassimo is Professor and Chair, Section of Pediatric Dentistry, The Ohio State University; Dr. Seale is Regents Professor
and Chair, Department of Pediatric Dentistry, Baylor College of Dentistry; and Dr. Ruehs is in private practice in Dallas, Texas.
Direct correspondence and requests for reprints to Dr. N. Sue Seale, Department of Pediatric Dentistry, Baylor College of
Dentistry, P.O. Box 660677, Dallas, TX 75266-0677; 214-828-8131 phone; 214-828-8132 fax; sseale@tambcd.edu. This study
was supported by the American Academy of Pediatric Dentistry, the American Dental Association, and the American Dental
Education Association.
Submitted for publication 9/15/03; accepted 11/19/03

T
he U.S. Surgeon General has identified chil-
dren with special health care needs (CSHCN)
among those groups who are experiencing
difficulty gaining access to dental care in the United
States.1 Newacheck et al.2 recently reported dental
care access a major concern of parents of CSHCN in
this country, validating the Surgeon General’s ob-
servations. As far back as three decades, reports in
the dental literature noted dentists’ reluctance to care
for disabled populations, suggesting that practitio-
ners experience numerous obstacles to care of the
disabled ranging from low reimbursement to inad-
equate dental school training.3 In the mid-1980s, cur-
riculum guidelines were established to assist dental
education in providing instruction about the needs
of special needs patients.4 These curriculum guide-
lines were issued a decade after a pilot program,
funded by the Robert Wood Johnson Foundation, to
train dental students to care for the handicapped
population; this program had positive, but limited
results.5
The shift to a competency-based education pro-
cess in dentistry in the 1990s brought with it changes
in the exposure of dental students to the disabled
population. A study by Romer et al.6 indicated that,
in 2000, dental students were receiving very limited
educational experiences in the care of the disabled
and those experiences varied widely in terms of di-
dactic, clinical, and hands-on mix.
The American Academy of Pediatric Dentistry
(AAPD) conducted a survey of approximately 5,000
general dental practitioners in the summer of 2001
to learn more about the care of children in their prac-
tices, in response to a resolution by the American
Dental Association (ADA) House of Delegates in
2000.7 Included in the survey was a series of ques-
tions about special needs patients. Specifically, gen-
eral dental practitioners were asked: did they pro-
vide care for CSHCN (children with cerebral palsy,
mental retardation, and those who are medically com-
promised); what were their perceptions of the train-
ing they received in dental school related to CSHCN;

January 2004 ■ Journal of Dental Education 23

 what was their interest in additional training for
CSHCN; and what factors influenced their willing-
ness to care for CSHCN?
An analysis of these data to determine the cur-
rent availability of dental care provided to CSHCN
by the general dentistry practicing community pro-
vides a baseline for future planning and educational
change. Therefore, the purpose of this report is to
present the analysis of this CSHCN-related data sub-
set as it relates to care by general dental practitio-
ners and to examine educational and environmental
factors that may affect general dentists’ practice pat-
terns related to children with special needs.
Materials and Methods
A random sample of 4,970 general practitio-
ners, chosen by the ADA survey center from the
ADA’s database and selected to be representative of
the nine ADA regions, served as the study popula-
tion. The survey methodology used to collect re-
sponses is described in depth elsewhere.8 Responses
from 1,251 general dentists concerning their prac-
tice patterns with CSHCN were available for an ad-
justed response rate of 24 percent. A comparison of
demographic data available from the ADA database
from responders and nonresponders indicated no sig-
nificant differences between the two groups.
Questions about respondents’ demographic
data included in this analysis were: year of gradua-
tion from dental school; additional training from an
accredited postdoctoral general dentistry program
including advanced education in general dentistry
(AEGD) or general practice residency (GPR); and
primary private practice location. Questions concern-
ing respondents’ practice patterns with children with
the special needs of cerebral palsy, mental retarda-
tion, and medical compromise included inquiries
about whether practitioners treated this category of
patients, how they were trained in dental school to
provide care for CSHCN, and whether they desired
additional training to treat CSHCN.
For the question that asked whether they treated
CSHCN, respondents were asked to use a 5-point
Likert-type scale: Very Often, Often, Sometimes,
Rarely, or Never. For dental school educational ex-
periences, respondents used a scale consisting of:
Hands-On/Lecture, Lecture Only, or None. To indi-
cate their attitude about the need for additional train-
24
ing, respondents used a scale consisting of: Very
Desirable, Desirable, Somewhat Desirable, or Not
Desirable. A question asked respondents to identify
to what degree various factors were perceived to be
a barrier to their willingness to see CSHCN. For each
potential barrier, they could choose “high, medium,
low, or no” as ratings. Respondents were asked how
frequently they performed specific procedures in-
cluding use of immobilization devices, stainless steel
crowns, and atraumatic restorative treatment (ART).
Respondents were asked whether they restore teeth
in children one to three years of age and if they use
different forms of pharmacologic behavior manage-
ment. Their willingness to treat non-special needs
children funded by Medicaid of all ages and with all
degrees of caries was also included in the data set.
Responses to these questions were reported as fre-
quencies and percentages.
Using Chi-squared analyses, respondents’ an-
swers to how frequently they treated each of the cat-
egories of special needs patients were compared with
their responses to 1) year of dental school gradua-
tion; 2) practice location; 3) attendance in a GPR or
AEGD program; 4) how frequently they perform
procedures including use of immobilization devices,
stainless steel crowns, nitrous oxide:oxygen sedation
alone, conscious sedation alone, and the combina-
tion of the two; 5) their willingness to treat non-spe-
cial needs children funded by Medicaid of all ages;
6) how they were educated in dental school about
treatment of CSHCN; 7) their desire for additional
training about treatment of CSHCN; and 8) how they
perceived barriers to their willingness to provide care
to CSHCN in general. Responses of “Very Often”
and “Often” were combined for these comparisons
as were the answers of “Rarely” and “Never” for
purposes of this analysis.
Responses to how practitioners were educated
in dental school about treatment of CSHCN were ad-
ditionally compared with 1) year of graduation from
dental school; 2) their desire for additional training
about treatment of CSHCN; and 3) how they per-
ceived specified issues as barriers to their willing-
ness to provide care to CSHCN in general.
Responses to how the practitioners perceived
various factors as barriers to willingness to provide
care to CSHCN were compared with their responses
about whether they had attended a GPR or AEGD
program. A significance level of p<0.05 was chosen
for all comparisons.
Journal of Dental Education ■ Volume 68, Number 1
Table 1. Responses about how frequently practitioners treat disabled children, how they were educated in dental
school to treat disabled children, and their desire for additional training
(Responses expressed as percentages)
I do this procedure Dental school I desire
in my practice… education was… more training…
(N=1237) (N=1157) (N=1133)

VO/O S R/N HL LO N VD/D SD ND

Cerebral Palsy 6 19 68 23 47 23 41 23 30
Mental Retardation 10 32 52 27 46 19 41 22 29
Medically Compromised 10 34 50 26 48 18 43 21 28

VO/O = Very Often/Often HL = Hands-on/Lecture VD/D = Very Desirable/Desirable

S = Sometime LO = Lecture/Lab Only SD = Somewhat Desirable
R/N = Rarely/Never N = None ND = Not Desirable

CSHCN. The only difference was that practitioners

Results with GPR training were significantly less likely
(p<0.05) to perceive the patients’ level of disability
Responses about how frequently practitioners or the patients’ behavior as barriers to their willing-
see CSHCN, how they were educated in dental school ness to see CSHCN.
to treat these patients, and their desire for additional The frequency with which practitioners re-
training are summarized in Table 1. Only about 10 ported seeing CSHCN significantly affected the types
percent of the general practitioners stated they saw of dental procedures they performed, whether they
CSHCN “Very Often” or “Often.” Nearly 70 per- saw non-special needs patients funded by Medicaid,
cent rarely or never saw children with cerebral palsy. their desire for additional training about treating spe-
Only about one-fourth had hands-on educational cial needs patients, and what barriers they perceived
experiences with CSHCN in dental school. Respon- to treating special needs patients. Those practitio-
dents’ answers about their desire for additional train- ners who report they see CSHCN often or very often
ing indicate that greater than 40 percent found addi- reported that they performed several dental proce-
tional training pertinent to treating CSHCN very dures significantly more often than general practi-
desirable or desirable. tioners who rarely or never saw CSHCN. These pro-
General dentists’ perceptions of barriers to their cedures included stainless steel crowns (CP and MR
willingness to see disabled children are summarized p<0.01, MC p<0.05) and nitrous oxide:oxygen anal-
in Table 2. By far, the greatest barrier was patient gesia, oral sedation, and the combination of these
behavior, with over 60 percent of respondents iden- two agents (p<0.001) (see Table 3). There were no
tifying it as a high-level barrier.
Chi-square analyses indicated no association
between the year a practitioner graduated from den-
Table 2. Practitioners’ perceptions of issues as
tal school and willingness to treat CSHCN. The size
barriers to their willingness to treat disabled children
of the community of the general practitioner affected (N=1185)
access to care for CSHCN. General dentists who
(Responses expressed as percentages)
practice in a community with a population <20,000 High Med Low No
were significantly more likely to see mentally re-
Patient’s behavior 64 20 6 4
tarded (p<0.01) and medically compromised
Level of disability 45 28 12 8
(p<0.05) children often or very often.
Respondents’ participation in GPR or AEGD Level of disease 33 32 17 12
programs had very little effect in increasing access My level of training 30 35 21 7
for CSHCN. There was no difference between those Office staff training 24 34 23 13
general practitioners with and without postgraduate Availability of funds 23 32 27 12
general dentistry training in their willingness to treat

January 2004 ■ Journal of Dental Education 25

 differences among the practitioners for the use of
immobilization devices.
There was a significant association between
general practitioners’ willingness to see CSHCN and
their willingness to be a Medicaid provider for chil-
dren in general. Those who reported that they treated
patients with special needs often/very often were sig-
nificantly more likely (p<0.001) to often/very often
see Medicaid patients of all ages (<3 years to 15
years).
Those practitioners who reported often/very
often treating CSHCN were significantly more likely
to report they desired additional training in treating
these special needs children (p<0.0001). They were
also significantly less likely to perceive the patients’
level of disability, dental disease, behavior, their
staffs’ level training, or their own training level as
barriers to their willingness to treat CSHCN as com-
pared with general practitioners who rarely or never
saw CSHCN (p<0.0001). The level of significance
for “availability of funding” as a barrier was less
uniform among the three types of special needs pa-
tients examined (CP p<0.05, MR p<0.001, MC
p<0.0001). These results are summarized in Table 4.
The types of educational experiences general
practitioners reported receiving in dental school about
treating CSHCN (HL = hands-on/lecture, LO = lec-
ture only, N = none) significantly affected whether
they treat CSHCN, how they perceived different fac-
tors as barriers to their willingness to provide care,
and whether they desired additional training in the
care of CSHCN. Practitioners who reported that they
received educational experiences with CSHCN in
dental school that were both hands-on and lecture
(HL) were significantly more likely to report that they
often or very often treated these patients (CP
p<0.0001; MR p<0.01; MC p<0.0001). Practitioners
who received no CSHCN educational experiences
in dental school were significantly more likely to
report that they never treated special needs patients
(CP p<0.0001; MR p<0.01; MC p<0.0001).
The impact of types of educational experiences
in dental school on practitioners’ perceptions of bar-
riers was not uniform for the three disabilities exam-
ined. Those who had both hands-on and lecture (HL)
experiences in treating cerebral palsy and medically
compromised patients were significantly less likely
to perceive the patients’ level of disability, level of

Table 3. General practitioners who often or very often treat disabled children are more likely to often or very often
perform the following procedures as compared with general practitioners who rarely or never treat disabled
children.
Cerebral Palsy Mentally Retarded Medically Compromised
(N=1040) (N=1050) (N=1045)

Stainless steel crowns p<0.01 p<0.01 p<0.001

N2O:O only p<0.0001 p<0.001 p<0.001
Oral sedation only p<0.0001 p<0.001 p<0.0001
N2O:O + oral sedation p<0.0001 p<0.0001 p<0.0001
Chi-square test

Table 4. General practitioners who often or very often treat disabled children perceive the following issues less
frequently as barriers to their willingness to treat them as compared with general practitioners who rarely or never
treat disabled children.
Cerebral Palsy Mentally Retarded Medically Compromised

Level of disability (N=1023) p<0.0001 p<0.0001 p<0.0001

Level of dental disease (N=1022) p<0.0001 p<0.0001 p<0.0001
Patient behavior (N=1018) p<0.0001 p<0.0001 p<0.0001
Level of staff training (N=1013) p<0.0001 p<0.0001 p<0.0001
Availability of funding (N=993) p<0.05 p<0.001 p<0.0001
Current level of training (N=905) p<0.0001 p<0.0001 p<0.0001
Chi-square test

26 Journal of Dental Education ■ Volume 68, Number 1

dental disease, behavior, their staff’s level of train-
ing, or their own level of training as barriers to their
willingness to treat these patients (p<0.05) as com-
pared with those who had lecture experiences only.
Those who had both hands-on and lecture (HL) ex-
periences about treating mentally retarded patients
were significantly less likely to perceive the patients’
level of disability, their staff’s level of training, or
their own level of training as barriers to their will-
ingness to treat them as compared with general prac-
titioners who had lecture experiences only. There
were no significant differences in their perceptions
of level of dental disease and patient’s behavior as
barriers compared with their educational experiences
in treatment of mentally retarded patients. The
method of training in dental school did not signifi-
cantly affect practitioners’ attitudes about availabil-
ity of funding as a barrier to care for all three types
of disabilities. These findings are summarized in
Table 5.
The practitioners’ dental school training in
CSHCN significantly affected whether they desired
additional training. Those practitioners who had HL
experiences in dental school about all three types of
special needs patients were significantly more likely
to desire additional training in CSHCN (CP p<0.01,
MR and MC p<0.05).
A comparison of the responses for types of
educational experiences in treatment of CSHCN in
dental school with year of graduation indicated sig-
nificant changes from the 1960s to the 1990s. Those
practitioners educated in the 1990s were significantly
less likely to state that they had no educational expe-
riences, and those trained in the 1960s were signifi-
cantly less likely to report that they had received
hands-on in combination with lecture experiences
(p<0.0001).
Table 5. General practitioners who had hands-on and lecture (HL) educational experiences in dental school with
disabled children less frequently perceive these issues as barriers to their willingness to treat these patients as
compared with general practitioners who had lecture experiences only.
Cerebral Palsy
Level of disability (N=984) p<0.05
Level of dental disease (N=984) p<0.05
Patient behavior (N=981) p<0.05
Level of staff training (N=976) p<0.05
Availability of funding (N=958) NS
Current level of training (N=877) p<0.0001
Chi-square test
January 2004 ■ Journal of Dental Education
Discussion
The data from this national study of general
dentists’ care of children offered a unique opportu-
nity to gauge the profession’s care of children who
also have special health care needs. The response
rate was modest, but we are confident that the data
provide a valid picture of access for CSHCN within
the general dental private practice system. Most avail-
able studies of practitioners’ care of special needs
populations are state-wide, regional, or alumni-
related9-11 and do not provide a comprehensive view
of care. In addition, our study focused on CSHCN
rather than a broader population of special needs
patients that includes adults and the elderly, which
can color results because of dentist preferences and
definitional difficulties. The findings from this sur-
vey indicating that fewer than one in ten general prac-
titioners often see children with cerebral palsy, men-
tal retardation, or who are medically compromised
confirms previous documentation1,2 that dental care
is one of the greatest unmet health care needs for
this population.
Results of this study on the effect of education
offer a confusing picture for care of CSHCN. Sup-
porting the positive effect of education on the likeli-
hood of caring for CSCHN was the finding that den-
tists who had not been exposed to hands-on and
lecture were less likely to care for these patients. It
is also encouraging to note that dentists who had been
educated in CSCHN care perceived fewer barriers
to providing care to special needs patients. However,
those with advanced education in GPR and AEGD
programs were not more likely to care for CSHCN,
while older dentists who tended not to have had spe-
cial needs patient education were more likely to care
Mentally Retarded Medically Compromised
p<0.01 p<0.001
NS p<0.05
NS p<0.05
p<0.01 p<0.01
NS NS
p<0.0001 p<0.0001
27
 for these patients. Casamassimo5 suggests that edu-
cational programs in care of special needs patients
do not necessarily increase the number of dentists
willing to care for these patients, but rather reinforce
the resolve of those practitioners who are already fa-
vorable to CSHCN care to try to help these individu-
als who have such overwhelming needs. When all is
said and done, it may be that the conflicting educa-
tion findings simply reaffirm the complexity of a
dentist’s decision to see CSHCN, based on finan-
cial, attitudinal, and educational factors.
Our data also show that three types of general
practitioners are more likely to see CSHCN: den-
tists practicing in small communities, dentists who
take Medicaid children without special needs, and
older dentists. We can surmise several possible ex-
planations for these findings. First, small town prac-
tice brings with it a closer relationship with patients
and community, making dentists more likely to care
for these patients. More troubling and boding ill for
the future is a possible interpretation that younger
dentists, heavily in debt, will not see Medicaid pa-
tients or those who might displace patients who can
afford care and require less effort. The apparent will-
ingness of older dentists to provide care for this popu-
lation, in spite of less CSHCN education, suggests
there may be an economic factor at play that over-
whelms education and good intentions. That is, older
established dentists do not have educational debt,
have sound financial practices, have dispensed with
home-buying and child-rearing expenses, and should
have financial stability; young practitioners must
confront all the above simultaneously. This interpre-
tation is bolstered by the consistency of Medicaid
acceptance for CSHCN and non-CSHCN in re-
sponses. If financial concerns truly overwhelm edu-
cation, this would be a major blow to improvement
in access as student debt worsens and financially
secure dentists retire in large numbers over the next
decade.12
All else being said, it is alarming to note that
only one in four general practitioners reported hav-
ing educational experiences with special needs pa-
tients. The dental education community is currently
looking at the place of special needs patients in ac-
28
creditation standards with a requirement for special
needs training a possibility.13 If our profession is to
address the needs of CSHCN, a major change must
occur in exposure of students to this population with
meaningful educational experiences for all.
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Journal of Dental Education ■ Volume 68, Number 1